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It Wasn’t The Insulin… Literally

I actually figured it out a few days ago, but I was so embarrassed that I didn’t want to talk about it. After a short talk with one of my board members yesterday, I’ve decided that to hold back would be bad. I feel I have a responsibility to share what really happened.

I made a really stupid mistake, and it cost me a lot of pain and misery. While it’s too early to tally up the financial figures (I haven’t received any of the hospital bills yet), I’m sure it cost me a pretty penny as well.

The thing is, I feel that I was a victim of my own over-complication. I feel that the whole experience was my fault. There’s that guilt thing again.

I was just trying to make things work for me. In the end, it was a perfect storm of circumstances, bad timing, and good intentions.

I have been using Symlin off and on for about a year and a half now. I think that it helps me, both in reducing the post-meal blood sugar spikes and in making me feel satisfied with less food. But I struggle with having to take shots again. I’ve been pumping my insulin for so long that I’ve gotten spoiled by the convenience and comfort of it. I know – crazy for a person with diabetes to bitch and moan about shots.

I put our problem solving skills to use and figured out a way to take advantage of the benefits symlin was providing without having to take shots again. I started pumping symlin in a second pump (an old, out of warranty pump).

Now, back to Wednesday night. I was planning my twice-monthly overnight trip to Iowa for work, with a morning departure around 4:00 or 4:30 AM. I had already worked a very long day and was really scrambling to get everything ready. I was also trying to get to bed early. I was zipping all over the house trying to prepare, and I realized that I needed to change all of my pump stuff and put in a new Navigator sensor.

If you are a pumper, your care team should have taught you to never change your pump stuff out at night before bed. My experience is a perfect example of why. Until this happened to me I thought that I had good reasons to change my stuff out at night. After this experience, I will do all I can to break that 12+ year habit.

To make a long story short(er), I loaded a cartridge of symlin into my insulin pump, and a cartridge of insulin into my symlin pump. Don’t ask me how I did this, because I really couldn’t tell you. My mind must have been thinking about a million things at once. They don’t even look the same (I only fill my symlin cartridge about halfway, but I fill my insulin cartridge completely).

The symlin didn’t really hurt anything. It just wasn’t insulin. What about the other pump? The one with insulin in it? I don’t wear the second pump around the clock, like I do with the insulin pump, but even if I did, the basal rates are set so low that it wouldn’t have saved me.

If I had been awake I would have felt “funny” and would have started to investigate. I would have had time to notice my blood sugars rising, and might have had a chance to fix things before they got to the point of no return. But because I was asleep, I didn’t even know anything was wrong. By the time I woke up it was already too late.

What about my Navigator CGM? Shouldn’t that have alarmed me that my blood sugar was high? I had put a new sensor in that night so it was still in the middle of its 10 hour calibration window (during which it does not give any readings or alarms). Bad timing would be a bit of an understatement.

I’ve changed a bunch of stuff in my routine to try and avoid this mistake in the future. I’m going to do all I can to not change my Navigator CGM sensor at the same time as my insulin infusion set. I’m going to do all I can to not change both pump sets at the same time. Finally, I’m not going to change my sets at night anymore if I can help it (even though I swear it takes the edges off the high blood sugar problems I have on a new site). That is my plan. DKA is no fun, and I’ll do whatever I can to avoid blood draws from my knuckles again.

It is still a great idea to check expiration dates on your insulin, but I don’t think there was anything wrong with the bottle I had. The stuff I loaded into my pump? It wasn’t the insulin.

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35 thoughts on “It Wasn’t The Insulin… Literally”

I am a parent of a 10 year-old with T1D and over the past 4 years I have made a couple of these types of mistakes. I was more than embarrassed, I felt guilty, like I abused my child. I am so thankful for the G4 longevity and accuracy! I am definitely going to take your advice about not changing sensors and infusion sets at night before bed. Sometimes the sensor is whacky and takes a while to start giving results, that most of our G4s start working within 2 hours.

I’m so glad you’re ok!( i’m just now catching up reading after a week with a cold) You know what?- we get into such a routine with things, that it’s easy to slip up. It’s like driving to work in the morning…sometimes we feel like we’re on autopilot.

as others have said, we all make mistakes and this is totally understandable. i can understand feeling embarassed, i have felt that way, but seriously, i am not judging you for that and i bet noone else is either (and if they are they suck).
since switching back from the pump to shots, i thought i mixed up my lantus and humalog at night several times. and one time i thought i accidentaly took my morning lantus dose of 32 instead of my evening lantus dose of 5. i never actually did, but i stayed up all night twice to find out. and i definitely almost did many times.
i think they should make the bottles look more different. i don’t know what the symlin bottle looks like – but i think it should be so clear to even a tired hurried mind that it’s different! the lantus and apidra bottles look WAY too alike. when i was taking both i would scribble with a blue permanent marker ALL OVER the lantus to help remind me of the difference. maybe that would be another helpful safeguard for you if the bottles look at all similar?

Like everybody else said, you are ok and that’s the most important. Mistakes happen. None of us are immune. It sucks when it happens but at least, you figured out a new game plan for the future. You figured out the problem and now you are taking steps to make sure that it doesn’t happen again. Nobody can ask for anything more… not even you! Give yourself a break 🙂

Glad to hear that you are doing okay!
I’ve been on the other end and know how scary it is to watch someone go through something like that. I’m glad to hear that you’re okay. Hang in there. Don’t beat yourself up over it.

Hard words to write. Well done on your part. You tried something and it didn’t work. I change my site at night all the time…so I’ll take my cue from you and reform. Better to lose that tiny bit of insulin.
Also, I can see that type 1 diabetes takes a back seat to nothing, in the way of making plans.
All the best to you Scott.

Scott:
You need to kill the Symlin pump dude!
It’s like shooting Novolog and Lantus in pens – pens were designed to be carried everywhere – and they bloody look the same.
I know you are still young – but you need to think forward and make sure things are as simple as possible.
Pump – insulin.
Shoot – Symlin.
No confusion.
When you get low, when you are in a hurry – it’s hard to screw it up if you K.I.S.S.
Thank you for sharing your confession – and trust me, we all make mistakes. Please remove the complexity – it increases your chances of failure.
drew

Hey, you found out the reason! And you came back to tell us all what really happened and the source of the trouble. That is nothing to be embarrassed about at all, and I thank you for sharing it. And even though we’re not supposed to do it, there are times when a pump change at bed time is unavoidable. I’m glad you are okay, and able to brush the dust off, and willing to tell about your experience, AND I’m glad you are still HERE for us 🙂

Oh Scott, I’m so glad you’re OK. And that is the kind of thing I’m likely to do… have accidentally taken more pain killers at times and it’s damn scary stuff.
Can I say DITTO to all that George said? I can? GREAT! DITTO!
Love and Hugs,
Gaelyne / FlitterbyG

So glad to hear you’re all right and while it’s frustrating, I know I would be very satisfied to figure out exactly why what happened did. Live and learn–and this is making me think twice about changing my pump sets before bed (something I do often). So you’re already helping others with your experience.

We all make mistakes, Scott. I went to work once without my pump on! I’m very glad that you told your story. It’s really important that we all remember to take our time around site changes and with all aspects of our diabetes care. 🙂

Dude,
I know what you mean about all this complication. I’ve never pumped Symlin before, but I have changed my sets out close to bedtime and I would probably do something like that, too, eventually.
Sorry you wound up in the ER. I can’t think of many places I would like to avoid more than that one.
Sounds like you have come up with some preventative measures that will help.
Take care!

1 – You’re okay – yay!
2 – You’re just like the rest of us, you made a mistake. We’ve all done it.
3 – You’re willing to share your mistake so others may not make the same mistake. I truly appreciate that you let us know what happened.
Thanks for being so open about the good – – – and the bad. It makes you honorable person!

So sorry Scott to hear about your recent episode. While we all know we’re only human and humans make mistakes and we should forgive ourselves and learn from our mistakes, sounds like you’re pretty hard on yourself. You may have some pretty big assumptions about life and about yourself that are skewing your vision.
I say give yourself a pat on the back for all the times you get it right and honor yourself for all the courage and strength you bring to living with this every day. You can start with the fact that sharing your story here says you’re brave in character and like to help others. Drink it in my friend!
riva

scott my friend.nothing i say right now really matters.you feel what you feel.been there.
i find it pretty dam awesome you have told us what happens.
in 2 yrs you will look back and laugh at this.
hope to see you soon and so glad you are back in the game.

What really upsets me the most is the feeling that you needed to hide the mistake. Don’t get me wrong, I’m completely the same way. But Scott, you are human. Humans make mistakes!! You are not a machine – and even if you were, machines fail too. I think every pumper knows that to be true. Things happen. It’s not really your fault. You didn’t knowingly mix up the cartridges. And once you woke up and knew you were in trouble, you took all of the steps to get help!! And are taking steps to further ward off a mix up in the futture. You rock, man!!!

Maybe I wasn’t clear: I’m not saying we can’t blame ourselves, but its never OK for others to blame us … the ownership of blame is not something others should automatically apply to PWD … we already have a lot of self-blame! Still, try to learn from the experience and move on, it’s a done deal!

Scott,
Again, like many others who have stated before me, the main thing is that you’re alright my friend.
But even more, as I told you before, you CAN’T beat yourself up about this. Yes I’m sure you’re wondering how the view is from the cheapseats…
As I have always said, one of the most vicious parts of the “D” is that it can make you feel so dumb so quick. No matter how on top of things you are, no matter how intelligent you are, no matter how good your intentions are…it doesn’t matter. Life certainly doesn’t fit into a nice box, and diabetes certainly is even further to the opposite extreme. When things like this occur, we feel we can only blame ourselves. Its the guilt and isolation aspects you have blogged about a hundred times before.
Don’t dwell on it buddy, all you can do is move on and try to make changes as you described above. Anybody that knows you, knows how hard you work to make everything “right”. Plus they share the same pain with the fight in their own life.
No one here will judge you, and you certainly shouldn’t spend a second of your time doing it either.
Keep this up I may have to sign you up for “Hollywood It’s All Good” motivational seminar! 🙂

I know I shouldn’t, but I had to laugh. Good you figured out the REAL problem though. I’m surprised you don’t wake up in the middle of the night to pee if your BG is high though. That’s usually my alert to a high BG in middle of night is that I wake up to go pee.

Very glad you came out OK in the end, Scott! Thank you for bravely writing about the whole thing, even the “operator error” part. I’m sure you saved someone a hospital trip with these two posts.
In the spirit of Scott Strumello’s excellent “Tuesday Tirade” about misplaced blame, guilt and patient responsibility…
People mix stuff up every day. We grab the wrong set of keys, bring the wrong notebook to class, we forget our cell phone. Switching two identical cartridges sounds way too easy to do. Totally sounds like something I could have done.
The problem isn’t carelessness–occasional human error is part of life. The problem is this disease: maintaining a supposedly “normal life” for fifty years or more on a solitary life support system, supported by a dangerous medication you can’t live a few hours without, where the penalty for a little mixup like this one is a day spent in life-threatening DKA.
You’ve just made it crystal clear why insulin therapy is no cure. Blame diabetes!

Like everyone else has more or less said, we are only human and do have a lot to remember. When I was on MDIs, I once thought I mixed up my lantus & humalog doses. Can you imagine? 25 units of humalog would’ve put me in a coma! Luckily I didn’t actually do it but it can happen. Please try not to beat yourself up about it and I guess learn from the experience even though it was a bad one 🙁 I’m glad you’re ok too!

Jeez, Scott. Talk about Murphy’s law. That was indeed the ultimate collection of unfortunate events. SO glad you’re okay. Great lesson for all of us though.
BTW, I didn’t know you were a Nav user. Me, too. Stay well, friend.

Wow Scott, that stinks. I was wondering why your CGM hadn’t woken you up.
I’m surprised the Symlin didn’t cause some lows. I can’t inject that stuff too early, it seems to switch off the output from my liver and I start to go low very quickly.
Anyway, I’m glad you figured out and I’m especially glad that you’re OK.

Glad you figured out the issue — and passed it on. The number of people this information will help, and possibly save, over the long term should overweigh any embarrassment you might feel from the incident.
That you figured out the cause and are working on ameliorating the situation is important.

Look at it this way, at least now you know exactly what happened rather than wondering. I’m just glad you are OK now. No one is perfect and you will set yourself up for disappointment if you expect perfection out of yourself. Just remember dude, #duckfiabetes completely!

Ha ha! The George always comes through, eh?!
Yeah Scott. Don’t hold on to that guilt. Life happens. Diabetes just happens to make it a bit more, annoying. We have so much to consider, so many variables.
The George is right, the most important part is You are okay!
We live, we learn.

Dude, with all we have to do, with all we have to think about, with the ZERO time off we get from that thinking, mistakes will happen. Don’t beat yourself up on this one, find Kayne. You can hit him and feel better about the whole thing.
Glad you are okay man. That’s the most important part.